Provider Demographics
NPI:1538349758
Name:MOSTAFA MIRHAIDARI, D.O.
Entity type:Organization
Organization Name:MOSTAFA MIRHAIDARI, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRHAIDARI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-364-8884
Mailing Address - Street 1:707 N WOOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2866
Mailing Address - Country:US
Mailing Address - Phone:330-364-8884
Mailing Address - Fax:
Practice Address - Street 1:707 N WOOSTER AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2866
Practice Address - Country:US
Practice Address - Phone:330-364-8884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34088184M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2544830Medicaid
OHP00282579OtherRAILROAD MEDICARE
OH2544830Medicaid
OHI32642Medicare UPIN